The rate of surgical complications has been estimated to be between 3-17%, worldwide. The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, identified human factors, communication, and information management to be among the top ten root causes for surgical complications in the past eight years. Data driven decision making is compromised by cognitive overload of surgeons and inability to quickly diffuse information to operating room teams, meaning that high-level patient management and performing attention dedicated technical skills are not always simultaneously exercised. Communication in the operating room is often marred by ambiguity of roles, dysfunctional teams, lack of situational awareness and unfamiliarity with surgeons' stylistic preferences. Studies have shown teamwork/communication disruption causes 52% of interruptions and distractions, and 10% of all communication breakdowns were seen to cause visible delays in surgery.
While checklists have positive effects, there is a need for a truly effective system covering a wide array of system failure modes such as communication breakdown, fatigue, inappropriate staffing, interruptions and inappropriate protocol.